The Vet Vault 3.2.1.

Hookworm's sneaky tricks, dislocated hips, the 'nasty' cat tumour that's not, and why you should become a dot collector

I love conferences, but my biggest frustration is that you go to all these amazing places and then spend all day in a lecture hall missing out on all the great things to see and do. Which is why I loved Vets On Tour when I attended one of their events a few years ago. In fact I loved it so much that the Vet Vault has officially partnered with them!

So here’s what we’re doing: we take the amazing specialist connections I’ve made through the years of doing Vet Vault, we fly a few of them somewhere amazing. Then we get a small group of vets to join us, and we do intimate engaging continuing education. But (and it's a big but!) - we also have fun. The learning is bunched in the early mornings and and evening so that we free up most of the day to do fun things, like skiing or hiking or surfing or whatever there is to do in the place that we picked.

Our first event is in Wānaka, NZ in the snow - an fan favourite of Vets On Tour die-hards, on 10-15 August, and we’ve just gone live with ticket sales. We have 25 early-bird tickets available, which will give you 20% off the full priced tickets. They are for sale until the end of March, or until they’re sold out - which, judging by how quickly our pre-sale tickets sold, will be soon!

Go to vetsontour.com for details and tickets

We’ll see you in the snow!

3 Clinical Pearls.

1. More hookworm sneaky tricks

From episode 185 in the Medicine feed. With Prof Peter Irwin

Our episode on hookworm with Prof Irwin originated from a series of text messages:

Me: "Peter, I have a frustrating case. My patient was treated two weeks ago for a heavy hookworm infestation. She improved, but now she has bad diarrhoea and inappetence again. Faecal float negative. WTF?!"

(Peter is a medicine specialist with a particular interest in parasites and vector-borne diseases—it's invaluable to have friends like this!)

Peter: "Sounds like she could have larval leak. Or she might be resistant to the dewormer you used."

Me: "We should do a podcast..."

Here's what I learned from that podcast:

• Larval leak refers to the phenomenon where hookworm larvae in a hypobiotic (dormant) state within tissues reactivate and migrate back to the intestine, leading to reinfection. This causes inflammation with associated GI signs. Note - it’s not drug resistance; it's part of the natural hookworm life cycle.

• The classic presentation is a dog that was diagnosed and treated for hookworm and then re-presents a few weeks later with ongoing gastrointestinal signs, with or without eggs visible on faecal testing.

• The absence of eggs can occur because even low-level infestations can cause chronic GI signs—sometimes too low to detect eggs on a float.

• Pro tip: Dogs with heavy initial burdens are more likely to experience multiple waves of larval emergence. (My patient was from 'up North' and had been on 'natural' deworming therapies, so she was pretty riddled on that first round!)

• Solution: A topical moxidectin product, like Advocate, will kill the adult worms in the gut and any larvae on their journey to 'leak' back into the GI tract.

As an aside, my patient was also mildly anaemic. Here's an additional insight:

• When treating the bad hookworm case, remember to include an iron supplement in your treatment plan. Many have been bleeding for a while, so without additional iron their bone marrow won't respond as effectively as you’d like.

2.  The dislocated hip that keeps popping out: you’re not the problem!

From our Advanced Surgery Podcast with Dr Mark Newman.

It always seems to happen on a weekend—the dog presenting with a dislocated hip. You optimistically anaesthetise the dog and, with considerable effort, reduce the hip (maybe applying an Ehmer sling?), optimistic that your patient might avoid surgery. (Makes you feel like a bit of a hero, right?) But by the time you reposition the dog for a follow-up X-ray, the hip has popped out again, or at the latest, when the patient gets up from it’s GA in its cage. Did you do something wrong?

This conversation with Dr Mark will make you feel better, and also help you to have more realistic discussions with your clients:

• The success rate of closed reduction is less than 50%. Significant structural damage is required for the femoral head to dislocate initially, making it challenging for those structures to heal while the animal bears weight without the head dislocating again.

• If there is significant dysplasia or fractures, that 50% success rate rapidly approaches zero.

So, is it even worth attempting? Well:

• If nothing else, reducing the hip provides immediate pain relief.

• Mark suggests considering closed reduction "if you have a small to medium dog with radiographically normal hip joints, a history of SOME trauma, but not severe trauma, and very compliant owners."

• Why "some trauma"? Because if it dislocated with minimal or no trauma, there's likely an underlying issue with that hip!

• What about Ehmer slings: there's no clear data showing that they reduce the chance of re-luxation. But there’s plenty evidence about the risks—over 50% of dogs with a sling experienced significant bandage-related complications! Some severe enough to require amputation. Additionally, interns applying Ehmer slings had a fourfold higher risk of complications compared to experienced surgeons. Study Link

My takeaway:

• I'll continue attempting closed reductions, but I’ll be much more pessimistic about the prognosis than I used to be. (As in: “this is likely to fail.”)

• Dr Mark : "I think the vast majority of dogs we see, we would be going straight to an open approach." (Spoken like a true surgeon!)

3. The ‘nasty’ cat tumour that’s not.

From Episode 187 in the Medicine Feed with Dr Sally Coggins

We’re talking FIP again with Dr Sally, specifically about cases of ‘treatment failure’ with the antivirals that turn out the just be misdiagnoses. Here’s one red herring that I’d never heard of:

• Eosinophilic sclerosing fibroplasia is a sneaky mass lesion that can pop up in the intestines of cats.

• They look really aggressive  on ultrasound, like a FIP granuloma, or even an adenocarcinoma.

BUT

• Most of the time they’ll go away with preds!

Takeaway: Biopsy those masses! (Or at least FNA)

(Here’s Sally about the case in question: “So that cat probably had four grand's worth of GS treatment unnecessarily, because the diagnosis of FIP was never confirmed.”:)

2 Other things

1. “It’s not your fault , but it is your responsibility.”

   — Dr Gabor Maté

2. “Being constantly accommodating when you don’t want to is not being nice. It’s insincere, enabling, and manipulative. It also breeds long-term resentment. That’s not nice; it’s a time-bomb.”

   — Tim Ferris

1 Thing to think about.

You can't connect the dots looking forward; you can only connect them looking backwards.

Steve Jobs

Later today I’m flying to Sydney to present an award to a well-deserving vet nurse. (Alfred-willing.) Next weekend I’m interviewing Japanese specialists and racing go-carts through the streets of Tokyo with some of the coolest vet nerds you’ll ever meet. For work. Yesterday I spent 3 hours writing show notes about the intricacies of mitochondria during critical disease and the lifecycle of hookworms - willingly! (And not without some enjoyment.) This month I’ve had conversations with business leaders, psychologists, programmers, surgeons, marketers, neurologists, and a professional audio engineer. I did some clinical vetting. Oh, and I’ve spent a LOT of time in conversation with artificial intelligence. (It even helped me pick an appropriate outfit for this evening’s award ceremony.)

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21-year old me would have had no way of imaging, never mind planning any of this. He just wanted to fix animals and not be so poor.

25-year old me thought he’d made a horrible mistake with his career choice. THIS was not what he’d signed up for! He spent a lot of time wondering what else, and if not what else, how better?

26-year old thought that what else might actually be where else, and moved to a different country.

28-year old me loved going to vet conferences to listen to smart people share their knowledge. But the best bits were always the questions that people asked after the lecture was over, because they were too embarrassed to ask them in front of everyone else.

30-year old me moved countries again.

35-your old me started an after hours business, because there was no after hours service in the area, and SOMEONE had to do it. And he wanted to see his young children during daylight hours. (But mainly because he wanted to surf more.)He also suddenly found himself doing long lonely commutes at weird hours and discover this cool new thing called ‘podcasts’ to keep him company.

40-year old me had finally figured out some of the ‘what else’ and the ‘how better.’ He had some free time and itchy feet, met this weird guy called Gerardo, started thinking about writing again, met some more interesting people…

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This is not a humble-brag, or a story of how “I made it.” I’m still figuring things out, and I’m not done yet. I don’t know how the dots will connect going forward. But what I am thinking about is that this peculiar and mostly pleasing way that my dots have CONNECTED is directly linked to the number and variety of dots that I had COLLECTED. Some of them were planned. Many of them weren’t. Quite a few felt like failures or dead ends at the time.

And what I'm learning is that as more connections are made, more dots come along to be collected and thrown on the path ahead of you, creating more options for unexpected connections to form. Basically, the more dots you have, the easier it is to connect them in interesting ways, which in turn creates more opportunities to collect ever more dots.

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We worry about making "the right" decisions. We try to pick "the path." We want to extrapolate into the next decade and beyond. But it doesn't work like that:

Yes, you should have a strategy and some goals, but all you can really do is collect interesting dots - experiences, skills, relationships, ideas - and trust that over time, meaningful patterns will emerge. Some dots will fade away. Others will suddenly connect in ways you never imagined.

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What dots do you have in your collection right now that you can connect in ways you haven’t considered yet? And which new dots are you curious to collect in the coming months and years?

Much love,

Hugh

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